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Transmission routes of 2019-nCoV and controls in

dental practice
Xian Peng1, Xin Xu1, Yuqing Li1, Lei Cheng1, Xuedong Zhou1 and Biao Ren 1

A novel β-coronavirus (2019-nCoV) caused severe and even fetal pneumonia explored in a seafood market of Wuhan city, Hubei
province, China, and rapidly spread to other provinces of China and other countries. The 2019-nCoV was different from SARS-CoV, but
shared the same host receptor the human angiotensin-converting enzyme 2 (ACE2). The natural host of 2019-nCoV may be the bat
Rhinolophus affinis as 2019-nCoV showed 96.2% of whole-genome identity to BatCoV RaTG13. The person-to-person transmission
routes of 2019-nCoV included direct transmission, such as cough, sneeze, droplet inhalation transmission, and contact transmission,
such as the contact with oral, nasal, and eye mucous membranes. 2019-nCoV can also be transmitted through the saliva, and the
fetal–oral routes may also be a potential person-to-person transmission route. The participants in dental practice expose to tremendous
risk of 2019-nCoV infection due to the face-to-face communication and the exposure to saliva, blood, and other body fluids, and the
handling of sharp instruments. Dental professionals play great roles in preventing the transmission of 2019-nCoV. Here we recommend
the infection control measures during dental practice to block the person-to-person transmission routes in dental clinics and hospitals.

International Journal of Oral Science (2020)12:9 ; https://doi.org/10.1038/s41368-020-0075-9

INTRODUCTION CHARACTERISTICS OF 2019 NOVEL CORONAVIRUS

An emergent pneumonia outbreak originated in Wuhan City, in
the late December 20191. The pneumonia infection has
rapidly spread from Wuhan to most other provinces and other
24 countries2,3. World Health Organization declared a public
health emergency of international concern over this global
pneumonia outbreak on 30th January 2020.
The typical clinical symptoms of the patients who suffered
from the novel viral pneumonia were fever, cough, and
myalgia or fatigue with abnormal chest CT, and the less
common symptoms were sputum production, headache,
hemoptysis, and diarrhea4–6. This new infectious agent is more
likely to affect older males to cause severe respiratory
diseases7,8. Some of the clinical symptoms were different from
the severe acute respiratory syndrome (SARS) caused by
SARS coronavirus (SARS-CoV) that happened in 2002–2003,
indicating that a new person-to-person transmission infectious
agent has caused this emergent viral pneumonia outbreak8,9.
Chinese researchers have quickly isolated a new virus from the
patient and sequenced its genome (29,903 nucleotides)10. The
infectious agent of this viral pneumonia happenening in
Wuhan was finally identified as a novel coronavirus (2019-
nCOV), the seventh member of the family of coronaviruses that
infect humans11. On 11th February 2020, WHO named the novel
viral pneumonia as “Corona Virus Disease (COVID19)”, while
the international Committee on Taxonomy of Viruses (ICTV)
suggested this novel coronavirus name as “SARS- CoV-2” due
to the phylogenetic and taxonomic analysis of this novel
coronavirus12.
Coronaviruses belong to the family of Coronaviridae, of the
order Nidovirales, comprising large, single, plus-stranded RNA
as their genome13,14. Currently, there are four genera of
coronaviruses: α- CoV, β-CoV, γ-CoV, and δ-CoV15,16. Most of
the coronavirus can cause the infectious diseases in human and
vertebrates. The α-CoV and β-CoV mainly infect the
respiratory, gastrointestinal, and central nervous system of
humans and mammals, while γ-CoV and δ-CoV mainly infect the
birds13,17–19.
Usually, several members of the coronavirus cause mild
respiratory disease in humans; however, SARS-CoV and the
Middle East respiratory syndrome coronavirus (MERS-CoV)
explored in 2002–2003 and in 2012, respectively, caused fatal
severe respiratory diseases20–22. The SARS-CoV and MERS-CoV
belong to the β-CoV23,24. 2019-nCoV explored in Wuhan also
belongs to the β-CoV according to the phylogenetic analysis
based on the viral genome10,11. Although the nucleotide
sequence similarity is less than 80% between 2019-nCoV and
SARS-CoV (about 79%) or MERS-CoV (about 50%), 2019-
nCoV can also cause the fetal infection and spread more
faster than the two other corona- viruses7,9,11,25–27. The genome
nucleotide sequence identity between a coronavirus (BatCoV
RaTG13) detected in the bat Rhinolophus affinis from Yunnan
Province, China, and 2019-nCoV, was 96.2%, indicating that
the natural host of 2019-nCoV may also be the Rhinolophus
affinis bat11. However, the differences may also suggest that
there is an or more intermediate hosts between the bat and
human. A research team from the South China Agricultural
University has invested more than 1 000 metagenomic
samples

1
State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Department of Cariology and Endodontics, West China Hospital of
Stomatology, Sichuan University, Chengdu, China
Correspondence: Xuedong Zhou (zhouxd@scu.edu.cn) or Biao Ren (renbiao@scu.edu.cn)

Received: 15 February 2020 Revised: 18 February 2020 Accepted: 19 February 2020

 Transmission routes of 2019-nCoV and controls in dental practice
Peng et al.
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from pangolins, and found that 70% pangolins contained β- Furthermore, it has been confirmed that
CoV28. One of the coronaviruses they isolated from the
pangolins comprised a genome that was very similar with that
from 2019-nCoV, and the genome sequence similarity was
99%, indicating that the pangolin may be the intermediate host
of 2019-nCoV29.
2019-nCoV possessed the typical coronavirus structure with
the “spike protein” in the membrane envelope30, and also
expressed other polyproteins, nucleoproteins, and membrane
proteins, such as RNA polymerase, 3-chymotrypsin-like
protease, papain-like protease, helicase, glycoprotein, and
accessory proteins10,11,30. The S protein from coronavirus can
bind to the receptors of the host to facilitate viral entry into
target cells31,32. Although there are four amino acid variations of
S protein between 2019-nCoV and SARS- CoV, 2019-nCoV can
also bind to the human angiotensin- converting enzyme 2
(ACE2), the same host receptor for SARS- CoV, as 2019-
nCoV can bind to the ACE2 receptor from the cells from
human, bat, civet cat, and pig, but it cannot bind to the cells
without ACE211,33–35. A recombinant ACE2-Ig antibody, a
SARS- CoV-specific human monoclonal antibody, and the
serum from a convalescent SARS-CoV-infected patient, which
can neutralize 2019-nCoV, confirmed ACE2 as the host receptor
for 2019-nCoV36–39. The high affinity between ACE2 and 2019-
nCoV S protein also suggested that the population with higher
expression of ACE2 might be more susceptible to 2019-
nCoV40,41. The cellular serine protease TMPRSS2 also
contributed to the S-protein priming of 2019-nCoV, indicating
that the TMPRSS2 inhibitor might constitute a treatment
option36.

THE POSSIBLE TRANSMISSION ROUTES OF 2019-NCOV

The common transmission routes of novel coronavirus include
direct transmission (cough, sneeze, and droplet inhalation
transmission) and contact transmission (contact with oral,
nasal, and eye mucous membranes)42. Although common
clinical manifestations of novel coronavirus infection do not
include eye symptoms, the analysis of conjunctival samples
from confirmed and suspected cases of 2019-nCoV suggests
that the transmission of 2019-nCoV is not limited to the
respiratory tract4, and that eye exposure may provide an
effective way for the virus to enter the body43.
In addition, studies have shown that respiratory viruses can
be transmitted from person to person through direct or indirect
contact, or through coarse or small droplets, and 2019-nCoV
can also be transmitted directly or indirectly through saliva44.
Notably, a report of one case of 2019-nCoV infection in
Germany indicates that transmission of the virus may also
occur through contact with asymptomatic patients45.
Studies have suggested that 2019-nCoV may be airborne
through aerosols formed during medical procedures46. It is
notable that 2019-nCoV RNA could also be detected by rRT-
PCR testing in a stool specimen collected on day 7 of the
patient’s illness47. However, the aerosol transmission route
and the fecal–oral transmission route concerned by the public
still need to be further studied and confirmed.

POSSIBLE TRANSMISSION ROUTES OF 2019-NCOV IN DENTAL

CLINICS
Since 2019-nCoV can be passed directly from person to
person by respiratory droplets, emerging evidence suggested
that it may also be transmitted through contact and fomites43,48.
In addition, the asymptomatic incubation period for individuals
infected with 2019-nCov has been reported to be ~1–14 days,
and after 24 days individuals were reported, and it was
confirmed that those without symptoms can spread the
virus4,5,49. To et al. reported that live viruses were present in
the saliva of infected individuals by viral culture method43.
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 Transmission routes of 2019-nCoV and controls in dental practice
Peng et al.
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2019-nCov enters the cell in the same path as SARS Human coronaviruses such as SARS-CoV, Middle East
coronavirus, that is, through the ACE2 cell receptor 25. 2019- Respiratory Syndrome coronavirus (MERS-CoV), or endemic
nCoV can effectively use ACE2 as a receptor to invade human corona- viruses (HCoV) can persist on surfaces like
cells, which may promote human-to-human transmission11. metal, glass, or plastic for up to a couple of days51,56. Therefore,
ACE2+ cells were found to be abundantly present contaminated surfaces that are frequently contacted in
throughout the respiratory tract, as well as the cells healthcare settings are a potential
morphologically compatible with salivary gland duct
epithelium in human mouth. ACE2+ epithelial cells of
salivary gland ducts were demonstrated to be a class early
targets of SARS- CoV infection50, and 2019-nCoV is likely to
be the same situation, although no research has been
reported so far.
Dental patients and professionals can be exposed to
pathogenic microorganisms, including viruses and bacteria
that infect the oral cavity and respiratory tract. Dental care
settings invariably carry the risk of 2019-nCoV infection due
to the specificity of its procedures, which involves face-to-
face communication with patients, and frequent exposure to
saliva, blood, and other body fluids, and the handling of
sharp instruments. The pathogenic microorganisms can be
transmitted in dental settings through inhalation of airborne
microorganisms that can remain suspended in the air for long
periods51, direct contact with blood, oral fluids, or other
patient materials52, contact of conjunctival, nasal, or oral
mucosa with droplets and aerosols containing
microorganisms generated from an infected individual and
propelled a short distance by coughing and talking without a
mask53,54, and indirect contact with contaminated instruments
and/or environmental surfaces50. Infections could be present
through any of these conditions involved in an infected
individual in dental clinics and hospitals, especially during
the outbreak of 2019-nCoV (Fig. 1).

Airborne spread
The airborne spread of SARS-Cov (severe acute respiratory
syndrome coronavirus) is well-reported in many literatures.
The dental papers show that many dental procedures
produce aerosols and droplets that are contaminated with
virus55. Thus, droplet and aerosol transmission of 2019-
nCoV are the most important concerns in dental clinics and
hospitals, because it is hard to avoid the generation of large
amounts of aerosol and droplet mixed with patient’s saliva
and even blood during dental practice53. In addition to the
infected patient’s cough and breathing, dental devices such
as high-speed dental handpiece uses high-speed gas to
drive the turbine to rotate at high speed and work with
running water. When dental devices work in the patient’s
oral cavity, a large amount of aerosol and droplets mixed
with the patient’s saliva or even blood will be generated.
Particles of droplets and aerosols are small enough to stay
airborne for an extended period before they settle on
environmental surfaces or enter the respiratory tract. Thus,
the 2019-nCoV has the potential to spread through droplets
and aerosols from infected individuals in dental clinics and
hospitals.

Contact spread
A dental professional’s frequent direct or indirect contact
with human fluids, patient materials, and contaminated
dental instru- ments or environmental surfaces makes a
possible route to the spread of viruses53. In addition, dental
professionals and other patients have likely contact of
conjunctival, nasal, or oral mucosa with droplets and
aerosols containing microorganisms generated from an
infected individual and propelled a short distance by
coughing and talking without a mask. Effective infection
control strategies are needed to prevent the spread of 2019-
nCoV through these contact routines.

Contaminated surfaces spread

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 Transmission routes of 2019-nCoV and controls in dental practice
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Airborne
Droplets
Susceptible individuals
Droplets and aerosols

Direct
contact Dental professionals

Infected patient Indirect

Dental practice contact
Contaminated surfaces

Fig. 1 Illustration of transmission routes of 2019-nCoV in dental clinics and hospitals

source of coronavirus transmission. Dental practices derived phase of the disease is not recommended to visit the dental clinic. If
droplets and aerosols from infected patients, which likely this does occur, the
contaminate the whole surface in dental offices. In addition, it
was shown at room temperature that HCoV remains infectious
from 2 h up to 9 days, and persists better at 50% compared
with 30% relative humidity. Thus, keeping a clean and dry
environment in the dental office would help decrease the
persistence of 2019- nCoV.

INFECTION CONTROLS FOR DENTAL PRACTICE

Dental professionals should be familiar with how 2019-nCoV is
spread, how to identify patients with 2019-nCoV infection, and
what extra-protective measures should be adopted during the
practice, in order to prevent the transmission of 2019-nCoV.
Here we recommend the infection control measures that should
be followed by dental professionals, particularly considering the
fact that aerosols and droplets were considered as the main
spread routes of 2019-nCoV. Our recommendations are based
on the Guideline for the Diagnosis and Treatment of Novel
Coronavirus Pneumonia (the 5th edition)
(http://www.nhc.gov.cn/yzygj/s7653p/202002/
3b09b894ac9b4204a79db5b8912d4440.shtml), the Guideline for the
Prevention and Control of Novel Coronavirus Pneumonia in Medical
Institutes (the 1st edition) (http://www.nhc.gov.cn/yzygj/s7659/
202001/b91fdab7c304431eb082d67847d27e14.shtml), and
the
Guideline for the Use of Medical Protective Equipment in the
Prevention and Control of Novel Coronavirus Pneumonia
(http://www.nhc.gov.cn/
yzygj/s7659/202001/e71c5de925a64eafbe1ce790debab5c6.shtml)
released by the National Health Commission of the People’s
Republic of China, and the practice experience in West China
Hospital of Stomatology related to the outbreak of 2019-nCoV
transmission.

Patient evaluation
First of all, dental professionals should be able to identify a
suspected case of COVID-19. To date that this paper was
drafted, the National Health Commission of the People’s
Republic of China has released the 5th edition of the Guideline
for the Diagnosis and Treatment of Novel Coronavirus Pneumonia.
In general, a patient with COVID-19 who is in the acute febrile
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dental professional should be able to identify the patient
with suspected 2019-nCoV infection, and should not
treat the patient in the dental clinic, but immediately
quarantine the patient and report to the infection control
department as soon as possible, particularly in the
epidemic period of 2019-nCoV.
The body temperature of the patient should be
measured in the first place. A contact-free forehead
thermometer is strongly recommended for the
screening. A questionnaire should be used to screen
patients with potential infection of 2019-nCoV before
they could be led to the dental chair-side. These
questions should include the following: (1) Do you have
fever or experience fever within the past 14 days? (2)
Have you experienced a recent onset of respiratory
problems, such as a cough or difficulty in breathing
within the past 14 days? (3) Have you, within the past
14 days, traveled to Wuhan city and its surrounding
areas, or visited the neighborhood with documented
2019-nCoV transmission? (4) Have you come into
contact with a patient with confirmed 2019- nCoV
infection within the past 14 days? (5) Have you come
into contact with people who come from Wuhan city and
its surrounding areas, or people from the neighborhood
with recent documented fever or respiratory problems
within the past
14 days? (6) Are there at least two people with
documented experience of fever or respiratory
problems within the last 14 days having close contact
with you? (7) Have you recently participated in any
gathering, meetings, or had close contact with many
unacquainted people?
If a patient replies “yes” to any of the screening
questions, and his/her body temperature is below 37.3
°C, the dentist can defer the treatment until 14 days
after the exposure event. The patient should be
instructed to self-quarantine at home and report any
fever experience or flu-like syndrome to the local health
department. If a patient replies “yes” to any of the
screening questions, and his/her body temperature is
no less than 37.3 °C, the patient should be immediately
quarantined, and the dental professionals should report
to the infection control department of the hospital or the
local health department. If a patient replies “no” to all
the screening questions, and his/her body temperature
is below 37.3 °C, the dentist can treat the patient with
extra- protection measures, and avoids spatter or
aerosol-generating procedures to the best. If a patient
replies “no” to all the screening questions, but his/her
body temperature is no less than 37.3 °C,

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the patient should be instructed to the fever clinics or special mouthrinse containing oxidative
clinics for COVID-19 for further medical care.

Hand hygiene
Fecal–oral transmission has been reported for 2019-nCoV, which
underlines the importance of hand hygiene for dental practice.
Although appropriate hand hygiene is the routine prerequisite
for dental practice, hand-washing compliance is relatively low,
which imposes a great challenge to the infection control during
the epidemic period of 2019-nCoV transmission.
Reinforcement for good hand hygiene is of the utmost
importance. A two-before- and-three-after hand hygiene
guideline is proposed by the infection control department of
the West China Hospital of Stomatology, Sichuan University,
to reinforce the compliance of hand washing. Specifically, the
oral professionals should wash their hands before patient
examination, before dental procedures, after touching the
patient, after touching the surroundings and equipment without
disinfection, and after touching the oral mucosa, damaged
skin or wound, blood, body fluid, secretion, and excreta. More
caution should be taken for the dental professionals to avoid
touching their own eyes, mouth, and nose.

Personal protective measures for the dental professionals

At present, there is no specific guideline for the protection of
dental professionals from 2019-nCoV infection in the dental
clinics and hospitals. Although no dental professional has been
reported to acquire 2019-nCoV infection to the date the paper
was drafted, the last experience with the SARS coronavirus
has shown vast numbers of acquired infection of medical
professionals in hospital settings57. Since airborne droplet
transmission of infection is considered as the main route of
spread, particularly in dental clinics and hospitals, barrier-
protection equipment, including protective eyewear, masks,
gloves, caps, face shields, and protective outwear, is strongly
recommended for all healthcare givers in the clinic/hospital
settings during the epidemic period of 2019-nCoV.
Based on the possibility of the spread of 2019-nCoV
infection, three-level protective measures of the dental
professionals are recommended for specific situations. (1)
Primary protection (standard protection for staff in clinical
settings). Wearing disposable working cap, disposable
surgical mask, and working clothes (white coat), using
protective goggles or face shield, and disposable latex gloves
or nitrile gloves if necessary. (2) Secondary protection (advanced
protection for dental professionals). Wearing disposable doctor
cap, disposable surgical mask, protective goggles, face
shield, and working clothes (white coat) with disposable
isolation clothing or surgical clothes outside, and disposable
latex gloves. (3) Tertiary protection (strengthened protection
when contact patient with suspected or confirmed 2019-nCoV
infection). Although a patient with 2019-nCoV infec- tion is not
expected to be treated in the dental clinic, in the unlikely event
that this does occur, and the dental professional cannot avoid
close contact, special protective outwear is needed. If
protective outwear is not available, working clothes (white
coat) with extra disposable protective clothing outside should
be worn. In addition, disposable doctor cap, protective goggles,
face shield, disposable surgical mask, disposable latex gloves,
and imperme- able shoe cover should be worn.

Mouthrinse before dental procedures

A preoperational antimicrobial mouthrinse is generally
believed to reduce the number of oral microbes. However, as
instructed by the Guideline for the Diagnosis and Treatment of
Novel Coronavirus Pneumonia (the 5th edition) released by the
National Health Commission of the People’s Republic of
China, chlorhexidine, which is commonly used as mouthrinse
in dental practice, may not be effective to kill 2019-nCoV.
Since 2019-nCoV is vulnerable to oxidation, preprocedural
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agents such as 1% hydrogen peroxide or 0.2% povidone is domestic waste generated by the treatment of patients with
recommended, for the purpose of reducing the salivary load suspected or confirmed 2019-nCoV infection are regarded as
of oral microbes, including potential 2019-nCoV carriage. A infectious medical waste. Double-layer yellow color medical
pre- procedural mouthrinse would be most useful in cases waste package bags and “gooseneck” ligation should be used.
when rubber dam cannot be used. The surface of the package bags should be marked and
disposed
Rubber dam isolation
The use of rubber dams can significantly minimize the
production of saliva- and blood-contaminated aerosol or
spatter, particularly in cases when high-speed handpieces
and dental ultrasonic devices are used. It has been reported
that the use of rubber dam could significantly reduce
airborne particles in ~3-foot diameter of the operational field
by 70%58. When rubber dam is applied, extra high-volume
suction for aerosol and spatter should be used during the
procedures along with regular suction59. In this case, the
implementation of a complete four-hand operation is also
necessary. If rubber dam isolation is not possible in some
cases, manual devices, such as Carisolv and hand scaler,
are recom- mended for caries removal and periodontal
scaling, in order to minimize the generation of aerosol as
much as possible.

Anti-retraction handpiece
The high-speed dental handpiece without anti-retraction
valves may aspirate and expel the debris and fluids during
the dental procedures. More importantly, the microbes,
including bacteria and virus, may further contaminate the air
and water tubes within the dental unit, and thus can
potentially cause cross-infection. Our study has shown that
the anti-retraction high-speed dental handpiece can
significantly reduce the backflow of oral bacteria and HBV
into the tubes of the handpiece and dental unit as compared
with the handpiece without anti-retraction function60.
Therefore, the use of dental handpieces without anti-
retraction function should be prohibited during the epidemic
period of COVID-19. Anti-retraction dental handpiece with
specially designed anti-retractive valves or other anti-reflux
designs are strongly recommended as an extra preventive
measure for cross- infection59. Therefore, the use of dental
handpieces without anti- retraction function should be
prohibited during the epidemic period of COVID-19. Anti-
retraction dental handpiece with specially designed anti-
retractive valves or other anti-reflux designs are strongly
recommended as an extra preventive measure for cross-
infection.

Disinfection of the clinic settings

Medical institutions should take effective and strict
disinfection measures in both clinic settings and public area.
The clinic settings should be cleaned and disinfected in
accordance with the Protocol for the Management of Surface
Cleaning and Disinfection of Medical Environment (WS/T 512-
2016) released by the National Health Commission of the
People’s Republic of China. Public areas and appliances
should also be frequently cleaned and disinfected, including
door handles, chairs, and desks. The elevator should be
disinfected regularly. People taking elevators should wear
masks correctly and avoid direct contact with buttons and
other objects.

Management of medical waste

The medical waste (including disposable protective
equipment after use) should be transported to the temporary
storage area of the medical institute timely. The reusable
instrument and items should be pretreated, cleaned,
sterilized, and properly stored in accordance with the
Protocol for the Disinfection and Sterilization of Dental Instrument
(WS 506-2016) released by the National Health Commission
of the People’s Republic of China. The medical and
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8
according to the requirement for the management of medical
waste.

SUMMARY
Since December 2019, the newly discovered coronavirus (2019-
nCov) has caused the outbreak of pneumonia in Wuhan and
throughout China. 2019-nCov enters host cells through human
cell receptor ACE2, the same with SARS-CoV, but with higher
binding affinity61. The rapidly increasing number of cases and
evidence of human-to-human transmission suggested that the
virus was more contagious than SARS-CoV and MERS-CoV9,25,27,61.
By mid-February 2020, a large number of infections of medical
staff have been reported62, and the specific reasons for the
failure of protection need to be further investigated. Although
clinics such as stomatology have been closed during the
epidemic, a large number of emergency patients still go to the
dental clinics and hospitals for treatment. We have summarized
the possible transmission routes of 2019-nCov in stomatology,
such as the airborne spread, contact spread, and contaminated
surface spread. We also reviewed several detailed practical
strategies to block virus transmission to provide a reference for
preventing the transmission of 2019-nCov during dental diagnosis
and treatment, including patient evaluation, hand hygiene,
personal protective measures for the dental professionals,
mouthrinse before dental procedures, rubber dam isolation, anti-
retraction handpiece, disinfection of the clinic settings, and
management of medical waste.

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